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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Tuesday, January 02, 2007

    Amen: The epidemic of diagnoses:

    This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction.

    Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.

    ...The epidemic of diagnoses has many causes. More diagnoses mean more money for drug manufacturers, hospitals, physicians and disease advocacy groups. Researchers, and even the disease-based organization of the National Institutes of Health, secure their stature (and financing) by promoting the detection of “their” disease. Medico-legal concerns also drive the epidemic. While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for overdiagnosis. Thus, the path of least resistance for clinicians is to diagnose liberally — even when we wonder if doing so really helps our patients.

    We're all a part of the problem.

    posted by Sydney on 1/02/2007 07:52:00 PM 4 comments


    Don't forget that patients demand a diagnosis, as well. I've always been a non-interventionalist at heart, but it's cost me patients, and revenue. Watchful waiting is a lost art.

    A secondary pronlem is that making a diagnosis from fuzzy indications can obfuscate the real diagnosis later on.

    By Anonymous Danie, at 10:07 AM  

    Too true.

    There's also a tendency for some patients to become heavily invested in the original fuzzy diagnosis, which makes it even harder to adequately treat the real diagnosis when it surfaces.

    By Blogger sydney, at 1:02 PM  

    Remember, from the other side of the desk, we as patients, are given diagnosis with great certainty, and often dire outcomes, if we do not follow the doctor's orders. Add to this many doctors desire to be cutting edge and you get people very quick to point to a problem that may or may not exist.

    Steve Lucas

    By Anonymous Anonymous, at 5:55 AM  

    I think the original article wasn't as much about patients' wanting a diagnosis for bothersome symptoms as about healthy symptomless people being converted into sick people for the sake of prevention.

    The authors specifically mentioned the ever-changing guidelines for preventive drugs. The also specifically mentioned overdiagnosis and overtreatment with testing.

    How many healthy symptomless people demand "diagnosis"? Yet instead of clearly explaining the real chance they will personally benefit, the doctors say "this will reduce your risk by n%" making an uninformed patient think he/she is in imminent danger without the drug. Many patients don't demandnon-recommended tests either yet many doctors order them. I understand some patients demand every test they see on TV, but those of us who don't would appreciate if they are not ordered without adequate reason and explanation why. Our relationship with doctors is not equal. I find it difficult to ask my doctor "why are you ordering urinalysis when USPSTF recommends against it?" because I don't want to be labelled "difficult". Sometimes it is just easier to comply and pray you will not be the one with a false positive or "overdiagnosed". And most people don't even know what is recommended and why. Most people don't understand that there is risk of harm with every test.

    As far as patients' not being afraid of overdiagnosis - most patients are not aware of it. Ads on TV don't mention it; websites describing the test don't mention it and doctors forget to mention it either. Those who heard the word don't appreciate the potential harm. Few realize that their chance of hearing the dreaded word "cancer" is higher if they are screened and that treatment for these overdiagnosed cases has serious risks. They also don't know the actual probability for them personally to benefit from each test. All they are told are "this is a horrible desease", "n people are diagnosed with it every year", "this test will reduce mortality by 30%" or the most ridiculous of all "more people survive 5 years after diagnosis if it is made early" (do doctors understand lead-time bias?). People who refuse are labelled "irresponsible"; if they do get the desease, they are made to feel guilty.

    With guidelines getting stricter and stricter and tests becoming more and more accurate, there soon will be no "healthy" people left.

    I think the solution is in making us more informed - more openness about risks and more accurate representation of the benefits, and presenting preventive drugs and tests as a personal choice and not an obligation. As a side benefit, you might get more informed juries in "this wasn't done early enough cases".

    By Anonymous Diora, at 11:11 AM  

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